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In psychiatric hospitals, the Centers for Medicare and Medicaid Services (CMS) requires a licensed independent practitioner to perform a face-to-face evaluation within one hour for any patient who is secluded or restrained for behavior management in all Medicare-certified medical and behavioral health care facilities. [42CFR482.13.f] CMS has defined seclusion as the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving; therefore, simply preventing a patient from leaving a hospital room could be considered seclusion. Recent definitions of restraint have drawn distinctions between holds used to prevent assault or administer “involuntary medications” and restraint, intended to limit the patient’s freedom of access to his/her body.

This “gray area” of regulation is a potential quagmire, because strict adherence would likely increase reporting of these restrictive interventions, at the same time hospitals and physicians are under pressure to find alternatives and show that their use is being reduced. Staff may then be divided into those who want to find ways to avoid reporting restrictions and those who wish to report every restriction of a patient’s freedom for fear of citations during surveys.

An alternative approach is to engage in a direct discussion of the implication of implementing these regulations in practice. To this end, we discussed these issues with James Courtney in the Georgia State Office of Regulatory Services (ORS). In addition to Mr. Courtney, the other participants in the discussion included were: Kim J. Masters M.D., Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, Georgia; Gayle Eckerd, Director Q/I Services, Focus by the Sea; and Ruby Durant, ORS.

The answers to the following questions represent the current understanding of the ORS staff, which have the responsibility of monitoring hospitals for compliance with both federal and state regulations. While these discussions were with staff in Georgia, similar answers would likely come from other states, because these are national regulations.

[They do not constitute legal opinions and may change over time as further clarification is provided by CMS or standards of practice change.]

Kim Masters: According to the current CMS rules for hospitals, seclusion means confining a person to a room or area, where the person is prevented from leaving. This would include a situation in which a staff member stood in an open doorway of the child’s room to keep the child from leaving. Would it be seclusion if the staff member did not tell the child he couldn’t leave, just stood there?

James Courtney: Yes. If a patient is restricted in a room and prevented from leaving, ORS surveyors would consider the action as meeting the definition of seclusion.

Gayle Eckerd: What if it was part of the patient’s treatment plan to spend time in his room or a quiet room when he became distressed.

JCORS: The use of quiet rooms, time-out rooms, or patient’s bedrooms for periods of time to allow patients an opportunity to regain self-control is not considered seclusion. If patients are physically prevented from leaving these rooms - even if the interventions were included on treatment plans, then surveyors would consider the action as seclusion. Keep in mind that seclusion is staff controlled, while the use of time-out and quiet rooms are patient controlled.

KM: What about restricting a patient to a locked unit within a ward?

JCORS: Confinement on a locked unit or ward where the patient is with others is not considered seclusion.

KM: You are certainly aware than all over America, every day children and adolescents are routinely sent to their room at home or to detention rooms at school. There is no requirement that a physician look at them to ensure they are medically and psychologically safe. Why should the same situation in a hospital require a doctor’s presence?

JCORS: The CMS rules and regulations include the right for a patient to be free from seclusion and restraint of any form except for emergency situations and only if needed to ensure the physical safety of the patient and/or others. Emergency is defined as a situation where the patient’s behavior is violent or aggressive and where the behavior presents an immediate and serious danger to self or others. The Medicare rules require a one-hour face-to-face assessment by a licensed independent practitioner in order to evaluate the patient’s current status and the need for treatment changes. Because the use of seclusion and restraint is required to be limited to emergency situations of violence and aggression, a comparison between the uses of school detention rooms or the use of bedrooms in homes cannot accurately be made.

KM: Let’s talk about restraint: is it a restraint if I grab a child’s hand to keep him from hitting me?

JCORS: A physical restraint according to CMS is any manual method - including holding a patient - or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts movement or normal access to ones body. If you are holding a child’s arm or leg to keep him from hitting or kicking and not otherwise limiting his motion, and it is for a brief period of time, certainly not to exceed 5 - 10 minutes, then generally it is not considered a restraint.

KM : What if I grab both arms or one arm and one leg?

JCORS: A Surveyor would want to look at the clinical record to review the incident, the child’s behavior and the intent of the intervention. Whether an action is considered restraint does not depend on the number of limbs grabbed by staff, but rather whether the hold restricts movement or patients’ access to their bodies. Most likely if staff holds three limbs, the intervention would be considered restraint.

KM: What about holding a patient to give him a medication, is that a restraint?

GE: Doesn’t it depend on whether the medication use is part of the patient’s treatment plan?

JCORS: Medication used for restraint is defined in part by CMS as “a drug used to control behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.” However, if it is necessary to hold the patient to administer the medication, the physical hold is a restraint - even if the medication given to the patient is considered a standard treatment of the patient’s psychiatric condition.

KM: Does this mean that if a child has a psychotic illness and his treatment plan calls for it to be given for acute psychotic decompensation, then it is neither a physical or chemical restraint?

JCORS: Medication given for a psychiatric illness, if it is considered a standard treatment for the illness, and is a part of the patient’s treatment plan is not considered a chemical restraint. If the patient’s behavior decompensates to the point that the medications are forced and physical holds are required to administer medications, then the physical holds would be considered a type of manual restraints.

KM: It appears that the seclusion and restraint regulations are attempting to define boundaries between patient’s agitation-provoked behaviors and patient’s behaviors that derive from their psychiatric illnesses.

JCORS: Yes, and for an important reason. The better we monitor, examine, assess, and treat patients’ dangerous behaviors, the more likely we are to keep them safe and reduce morbidity and mortality.

There you have it, everything you wanted to know about those gray areas in seclusion and restraint and were afraid to ask. By all means, if other questions come to mind, you can look up the web site, at www.cms.hhs.gov/cop/2b.asp. Even better, you may contact your State’s CMS survey representative to help clarify these issues. Maybe with ongoing discussions and data collection, we can together determine whether it would be possible for less intrusive interventions to provide the same level of safety. If you are collecting data on seclusion and restraint issues, please remember to send it to Michelle Morse using the format described in this column in May 2002. The data is also posted online in the AACAP Members section.

Dr. Masters is Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, GA. He is also co-author of AACAP’s Practice Parameter on the Prevention of Aggressive Behavior.